CASE STUDY #32

ACUTE LYMPHOBLASTIC
LEUKEMIA TREATED WITH
HEMATOPOIETIC STEM CELL
TRANSPLANTATION

Ka r l y C h il d re s s
Denielle Saitta
M o ll y C h a ffi n
C l a i re H o ll a d a y
L a u re n M i t c h e l l

ACUTE LYMPHOBLASTIC LEUKEMIA

Leukemia is a type of cancer that aff ects the blood
and bone marrow
Common Types of Leukemia:

Acute Myeloid Leukemia (AML)

Acute Lymphoblastic Leukemia (ALL)
Chronic Myeloid Leukemia (CML)
Chronic Lymphocytic Leukemia

Patients with acute leukemia have a more aggressive

disease than those with chronic leukemia

ALL, CONT.
Bone marrow makes bloo d
st em cells t hat b ecom e
mat ure bloo d cells over t im e
A bloo d st em cell may
become a m yelo id stem c ell
or a lympho id stem cell
Myelo id st em cell bec om es
one of t hree t ypes of m a ture
blo od cells
Red blood cells
Platelets
White blood cells

Lymphoid stem cell beco m es

a lympho blas t cell and t hen
one of t hree t ypes of
lymphocyt es
B lymphocytes
T lymphocytes
Natural killer cells

SIGNS AND SYMPTOMS OF ALL

HEMATOPOIETIC STEM CELL

TRANSPLANTATION
Hematopoietic stem cell transplant is a procedure
that restores stem cells that have been destroyed by
high doses of chemotherapy and/or radiation therapy
Three types of transplants:
Autologous transplant
Allogeneic transplant
Syngeneic transplant

MEET SCOTT BEAR

CLIENT HISTORY (CH)

Personal History

28 year old, white male

Marital Status: Married with three children
Tobacco use: pack daily, states he quit this morning
Alcohol use: 1 drink daily, beer or alcohol
Mobility: Ambulatory

Hematology/Oncology History
Chief Complaint: Im here to get some new cells.
Diagnosed with ALL in 2008
He was doing well until Spring 2012
Admitted with fever, fatigue, dyspnea, and red spots on his skin
Diagnosis: Relapse of Pre-B cell ALL and started on HyperCVAD (5
cycles prior to admission)

CLIENT HISTORY (CH)

Musculoskeletal History
osteomyelitis, back pain
Psychological History
anxiety, depression

Family History
Mother: Diabetes
Father: Hypertension

Other History
Obesity
Treatments/Therapy
Surgical treatment
ALL admitted to the transplant unit for a 10/10 HLA matched
unrelated donor transplant with myeloablative
cyclophosphamide and total body irradiation

CLIENT HISTORY (CH)

Admission Orders (11/7)
ALT/AST, Bilirubin: total and direct
CMV, PT, IRN, PTT: on admit and every Monday/Thursday
Calcium/Phosphate: on admit and every Monday/Thursday
CVC, Edit, Platelet: on admit and every two days
Chem 7, Magnesium: on admit and daily
Prealbumin: on admit
Vital Signs
Every 4 hours
Diet: Regular/Low bacterial

ANTHROPOMETRIC MEASUREMENTS
(AD)
Height: 59
Weight: 198 lbs
BMI: 29.4 kg/m 2
Overweight

50lb unplanned weight loss during fi rst round of

chemotherapy (2008)
22% unplanned weight loss
Regained 20 lbs to current 198lb

NUTRITION-FOCUSED PHYSICAL
FINDINGS (PD)
Upon Admission (11/7)
Overall Appearance
Comfortable, not in acute distress, well-nourished
Skin warm and dry, not perspiring

Chest/Abdomen
Clear to auscultation
Abdomen: soft, nontender, nondistended

Vital Signs

Temp: 98.2
Pulse: 80
Resp rate: 16
BP: 126/78

NUTRITION-FOCUSED PHYSICAL
FINDINGS (PD)
16 days post-op
Overall Appearance
Macropapular rash on palms and trunk
Grade 2 mucositis in mouth

Chest/Abdomen
Clear to auscultation
Firm, tense hyperactive BSx4

Vital Signs (16 days post-op)

Temp: 98.4
Pulse: 83
Resp rate: 20
BP: 130/82

BIOCHEMICAL DATA, MEDICAL

TESTS AND PROCEDURES (BD)
Lab

Reference
Range

Admission

Post-op day 16

BUN (mg/dL)

8-18

13

23 H

BUN/Crea ratio

10.0-20.0

13

23 H

Albumin (g/dL)

3.5-5

3.5

2L

Prealbumin
(mg/dL)

16-35

24

<1 L

BIOCHEMICAL DATA, MEDICAL

TESTS AND PROCEDURES (BD)
Hematology
Lab

Reference
Range

Admission

Post-op day 16

WBC count
(x103/mm3)

4.8-11.8

4.5 L

2.9 L

RBC count
(x106/mm3)

4.5-6.2 (M)

2.82 L

2.33 L

Hemoglobin
(Hgb, g/dL)

14-17 (M)

9.8 L

7.9 L

Hematrocrit (Hct, 40-54 (m)

%)

29.1 L

23.7 L

Mean Cell Hgb

(pg)

26-32

20.4 L

16.5 L

RBC distribution
(%)

11.6-16.5

7.6 L

8.9 L

FOOD AND NUTRITION-RELATED

HISTORY (FH): FOOD AND
NUTRIENT INTAKE
48-hour food recall shows regular and suffi cient food
intake
Likely meeting >100% of calorie and protein needs

FOOD AND NUTRITION-RELATED

HISTORY (FH): FOOD AND
NUTRIENT INTAKE
Current Medications upon admission (11/7)

FOOD AND NUTRITION-RELATED

HISTORY (FH): FOOD AND
NUTRIENT INTAKE
Medication Plan as of 11/30

FOOD AND NUTRITION-RELATED

HISTORY (FH): FOOD AND
NUTRIENT INTAKE
Medication Plan as of 11/30, cont

FOOD AND NUTRITION-RELATED

HISTORY (FH): FOOD AND
NUTRIENT INTAKE
Medication Plan as of 11/30, cont

COMPARATIVE STANDARDS (CS)

REE (using Miffl in St. Jeor equation):
(10 x 90 kg) + (6.25 x 175cm) (5 x 28 y) + 5 = 1,858.75
kcal/day

TEE
1.2 Activity Factor (hospitalized)= 2,230 kcal
1.0-1.3 injury factor due to surgery
2,230-2,900 kcal/day

COMPARATIVE STANDARDS (CS)

Macronutrient needs
Normal protein requirements (0.8-1.0 g/kg body weight)
= 72-90 g/day

Post-operative needs (1.0-1.5g/kg body weight)

= 90-135 g/day

Fluid needs: 1mL/kcal consumed

2.2-2.9 L/day = 9 (8 oz.) glasses per day

Fiber needs = 31 g/day

COMPARATIVE STANDARDS (CS)

Micronutrient Needs

Calcium: 1,000 mg/day

Vitamin D: 15 mcg/day
Potassium: 4,700 mg/day
Selenium: 55 mcg/day
Vitamin B6: 1.3 mg/day

NUTRITION DIAGNOSES
PES #1:
Altered GI function (NC-1.4) related to chemotherapy and
total body irradiation as evidenced by 3.5 L liquid stool past
24 hours.

PES #2:
Altered nutrition related lab values (WBC, NC-2.2) related to
cancer treatment as evidenced by 2.9 White blood cell
count.

NUTRITION INTERVENTION
PES #1: Altered GI function (NC-1.4) related to
chemotherapy and total body irradiation as evidenced
by 3.5 L liquid stool past 24 hours.
Nutrition Rx: Meeting nutritional needs through
bypassing the GI tract..
Nutrition Intervention: Initiate Parenteral Nutrition (2.2)
Dextrose: 571 mL ; D70 ; 400g 1360 Kcals
A A:
900 mL ; 15% A A; 135g 540Kkcals
IVFE:
200 mL ; 20% IVFE ; 40g 400 Kcals
Total: 2,300 Kcals

NUTRITION INTERVENTION
PES #2: Altered nutrition related lab values (WBC, NC2.2) related to cancer treatment as evidenced by 2.9
White blood cell count.
Nutrition Rx: Modify diet to a low microbial diet with high
protein, adequate energy.
Nutrition Intervention: A low microbial diet includes
avoiding raw/undercooked foods such as seafood, eggs,
vegetables, undercooked meats, unpeeled fruits, or
unpasteurized dairy products. This diet will reduce the
chance of Mr. Bear becoming ill while his immune system
is weak. Educate the patient on the importance of food
safety and how this contributes to the low microbial diet.

MONITORING AND EVALUATION

Monitor anthropometrics by checking weight, BMI, and waist
circumference to prevent weight loss
Evaluate the patients knowledge of the microbial diet and
what he should and should not eat when his immune system
is suppressed
Evaluate the patients re cell blood counts in order to reduce
chance of infection
Increase the patients fi ber and water intake to reduce the
chance of diarrhea
Monitor the patients protein levels in order to keep blood
counts high and stable
Monitor patient for symptoms of GVHD ( Graft-versus-host
disease) such as jaundice, abdominal pain, dry or irritated
eyes, fatigue, muscle weakness, weight loss, etc
Monitor White Blood cells Counts
Monitor patients energy intake as well as macronutrients
intake

ADIME NOTES
Client History
28 y/o white male, married with 3 children
Acute lymphoblastic leukemia (ALL)
Admitted to transplant unit for a 10/10 HLA MUD with
myeloablative cyclophosphamide and total body irradiation
1 alcoholic drink daily and smokes pack daily

Anthropometric Data
Height: 59 Weight: 198 lbs BMI: 29.4

Physical Findings
Macropapular rash on palms and trunk
Grade 2 mucositis in mouth
Patient reports feeing fatigued, complains of mouth
pain/discomfort from rash
Diarrhea continues with occasional nausea

Vital Signs
Temperature: 98.4 Pulse: 83 Blood Pressure: 130/82

ADIME NOTES
Biochemical Data

ADIME NOTES
Food and Nutrition Related History
Patient states that usual body weight was 230 lbs
Prior to diagnosis and with initial chemo treatment in
2008, patient lost 50 lbs. The next year, patient
gained 20 lbs
48-hour recall shows intake prior to admission good
and likely meeting >100% of calorie and proteins
needs

Comparative Standards
Kcal: 1,858.75 kcal/day
Protein: Post-op 90-135 g/day
Fluid: 2.2-2.9 L/day = 9 (8 oz.) glasses per day

ADIME NOTES
Dia gnosis & In t er v en ti on
PE S #1 :Al te red GI fu n ct ion (NC- 1 .4 ) rel a t ed t o c hem ot h er a py a n d to ta l
body irr a dia ti on a s ev i de nce d by 3 .5 L li qui d st ool pa st 2 4 h ou r s.
Nut r it ion R x : M e et in g n utr i tio na l ne eds t hrough by pa ssin g t h e G I t r a c t.
Nut r it ion In t er v en ti on : Ini tia te Pa rent er a l Nutr i ti on ( 2 .2 )
Dex t rose: 5 7 1 m L ; D7 0 ; 4 0 0g
1 3 6 0 K c a ls
A A:
9 0 0 m L ; 1 5 % A A; 1 3 5 g 5 4 0 Kk c a ls
IV F E :
2 0 0 m L ; 2 0 % IVF E ; 4 0 g 4 0 0 K ca ls
Total: 2,300 Kcals
PE S #2 : Alt ere d n u tr i tio n rela te d la b v a lue s (W BC, NC- 2 .2 ) rel a te d t o
ca nce r t rea tm e nt a s ev i de nce d by 2 .9 W hi te blo od c ell c ou n t
Nut r it ion R x : M odi fy di et t o a lo w m i crobia l di et w it h h igh prot ei n ,
a dequa t e en ergy.
Nut r it ion In t er v en ti on : This c a n be done t hrough a v oi din g
r a w /underc ooked f oods ( sea foo d, e ggs, v eget a bl es, un derc ooke d
m ea ts, unpee le d f ru i ts or unpa ste ur iz ed da ir y produ ct s. Thi s die t w i ll
re duc e the ch a nc e of th e pa tie nt be co m i ng il l w hi le h is im m u n e
sy st em i s w ea k. E du ca te the pa t ient o n the im por t a n c e o f f ood sa fe ty
a nd how th is c on t r ibut e s to the lo w m ic ro bi a l die t.

ADIME NOTES
Monitor anthropometrics by checking weight, BMI, and
waist circumference to prevent weight loss
Evaluate the patients knowledge of the microbial diet and
what he should and should not eat when his immune
system is suppressed
Evaluate the patients blood counts in order to reduce
chance of infection through low blood counts
Increase the patients fi ber and water intake to reduce the
chance of diarrhea
Monitor the patients protein levels in order to keep blood
counts high and stable
Monitor patient for symptoms of GVHD ( Graft-versus-host
disease) such as jaundice, abdominal pain, dry or irritated
eyes, fatigue, muscle weakness, weight loss, etc
Monitor White Blood cells Counts
Monitor patients energy intake as well as macronutrient
intake

REFERENCES
Nahikian-Nelms, Marcia, and Sara Long. Roth. Medical
Nutrition Therapy: A Case Study Approach . Belmont,
CA: Wadsworth/Thomson Learning, 4 t h ed., copyright
2014. Print.
Internet Resources

American Cancer Society: www.cancer.org

National Cancer Institute: www.cancer.gov
Nutrition Care Manual: www.nutritioncaremanual.org
Dietary Guidelines for Americans 2010:
www.dietaryguidelines.gov